Because the control and monitoring of the escalators are divided between the deck and engine room staff, no one is in overall charge of the escalators' operation. Deck staff reset the escalators for direction of flow and the engine room staff monitor their safe operation by means of the video camera system. The monitoring video cameras are poorly positioned. Only portions of the upper part of each escalator can be seen when the escalators are carrying passengers. The video monitors in the engine room control room are also poorly sited as the engineer's view of them from the main engine station, should operational requirements or emergency drills leave only one engineer in the control room, is blocked by a partial bulkhead. The engineer has a choice of monitoring either the engines or the escalators, but cannot do both. Even when an engineer is looking at the monitors, the siting of the cameras is such that potential trouble cannot be seen to be developing. The engineer can thus only react to a situation which has already developed, e.g., when passengers are seen to be in trouble. The students were allowed to carry on their baggage instead of using the ferry corporation's baggage system. The effect of this was to add to the congestion on the escalators during disembarkation. This could have been avoided had any of the supervisors told them to use the baggage system when disembarking from the school buses. The sign on the upper car deck door states: All foot passengers disembark on the main car deck, but there is no sign to tell the passengers where they are while reading the sign on the door. The size and location of the sign telling passengers to disembark on the main deck means that passengers are required to get close to the door and to be paying attention in order to read it. Nothing indicates that passengers must continue down the escalators to get to the main car deck. As a result, students unfamiliar with the ferry exited the escalator tower to the upper car deck. This indicates that the signs in the escalator tower did not achieve their purpose. Additionally, signs are almost exclusively unilingual English, without the benefit of graphics or a second language. It is not difficult for a disembarking passenger, unfamiliar with the ship, to pass on the wrong side of the waist-high barrier in the hallway on the upper car deck level of the escalator tower. The design and layout of the barrier also prevented the students from easily re-entering the traffic flow. The fact that the installation and inspection of escalators on board ships are covered by the Canadian Standards Association (CSA) B 44-1975 Code, which does not require direct inspection by Transport Canada Marine Safety Inspectors, means that escalators are treated as a normal stairway by inspectors. However, escalators are not normal stairways because the tread heights of a stopped escalator vary. Passengers who use the stopped escalator as a stairway between terminals may be unaware of this. The varying tread height may cause passengers to trip or to fall.Analysis Because the control and monitoring of the escalators are divided between the deck and engine room staff, no one is in overall charge of the escalators' operation. Deck staff reset the escalators for direction of flow and the engine room staff monitor their safe operation by means of the video camera system. The monitoring video cameras are poorly positioned. Only portions of the upper part of each escalator can be seen when the escalators are carrying passengers. The video monitors in the engine room control room are also poorly sited as the engineer's view of them from the main engine station, should operational requirements or emergency drills leave only one engineer in the control room, is blocked by a partial bulkhead. The engineer has a choice of monitoring either the engines or the escalators, but cannot do both. Even when an engineer is looking at the monitors, the siting of the cameras is such that potential trouble cannot be seen to be developing. The engineer can thus only react to a situation which has already developed, e.g., when passengers are seen to be in trouble. The students were allowed to carry on their baggage instead of using the ferry corporation's baggage system. The effect of this was to add to the congestion on the escalators during disembarkation. This could have been avoided had any of the supervisors told them to use the baggage system when disembarking from the school buses. The sign on the upper car deck door states: All foot passengers disembark on the main car deck, but there is no sign to tell the passengers where they are while reading the sign on the door. The size and location of the sign telling passengers to disembark on the main deck means that passengers are required to get close to the door and to be paying attention in order to read it. Nothing indicates that passengers must continue down the escalators to get to the main car deck. As a result, students unfamiliar with the ferry exited the escalator tower to the upper car deck. This indicates that the signs in the escalator tower did not achieve their purpose. Additionally, signs are almost exclusively unilingual English, without the benefit of graphics or a second language. It is not difficult for a disembarking passenger, unfamiliar with the ship, to pass on the wrong side of the waist-high barrier in the hallway on the upper car deck level of the escalator tower. The design and layout of the barrier also prevented the students from easily re-entering the traffic flow. The fact that the installation and inspection of escalators on board ships are covered by the Canadian Standards Association (CSA) B 44-1975 Code, which does not require direct inspection by Transport Canada Marine Safety Inspectors, means that escalators are treated as a normal stairway by inspectors. However, escalators are not normal stairways because the tread heights of a stopped escalator vary. Passengers who use the stopped escalator as a stairway between terminals may be unaware of this. The varying tread height may cause passengers to trip or to fall. The students, carrying bulky baggage, were allowed to proceed to the disembarkation point without direct supervision from the adults in the school party. There is no sign in the escalator towers that identifies the various car deck levels. The small sign indicating that passengers should disembark on the main car deck is placed where it cannot be seen by passengers prior to their arrival at the upper car deck level of the escalator towers. There is no sign at the upper car deck level to instruct passengers on foot to continue down the escalators for a further two levels to the main car deck. Some students, unfamiliar with the ferry layout, mistakenly exited the escalator tower at the upper car deck level, the level at which they had boarded. When the students attempted to re-enter the escalator tower, the placement of the traffic control barrier on at the upper car deck level of the escalator tower directed them against the flow of passengers stepping off the upper escalator. The resulting congestion blocked the exit of descending passengers, trapped them on the moving escalator and caused many to fall. Of the passengers who fell, one sustained injuries which required her hospitalization. In addition, she and another passenger were immobilized by clothing trapped between the escalator treads. The siting of both cameras and monitors of the escalator surveillance system does not allow the vessel's engineers to simultaneously monitor the escalators, monitor the Engine Control Panel, and if necessary manoeuvre the engines in an emergency or drill.Findings The students, carrying bulky baggage, were allowed to proceed to the disembarkation point without direct supervision from the adults in the school party. There is no sign in the escalator towers that identifies the various car deck levels. The small sign indicating that passengers should disembark on the main car deck is placed where it cannot be seen by passengers prior to their arrival at the upper car deck level of the escalator towers. There is no sign at the upper car deck level to instruct passengers on foot to continue down the escalators for a further two levels to the main car deck. Some students, unfamiliar with the ferry layout, mistakenly exited the escalator tower at the upper car deck level, the level at which they had boarded. When the students attempted to re-enter the escalator tower, the placement of the traffic control barrier on at the upper car deck level of the escalator tower directed them against the flow of passengers stepping off the upper escalator. The resulting congestion blocked the exit of descending passengers, trapped them on the moving escalator and caused many to fall. Of the passengers who fell, one sustained injuries which required her hospitalization. In addition, she and another passenger were immobilized by clothing trapped between the escalator treads. The siting of both cameras and monitors of the escalator surveillance system does not allow the vessel's engineers to simultaneously monitor the escalators, monitor the Engine Control Panel, and if necessary manoeuvre the engines in an emergency or drill. The placement, size and content of passenger instruction signs in the escalator towers were inadequate to ensure that passengers on foot proceeded to the correct deck to disembark. Some unsupervised students mistakenly left the tower at the upper car deck level. When the students attempted to rejoin the flow of passengers in the tower, they were hindered by a control barrier at the foot of the escalator and by the bulky baggage they and the passengers on the escalator carried. The area quickly became congested and passengers on the moving escalator were unable to leave it. Two of the many passengers who fell backwards were injured, one of whom required hospitalization. The escalator surveillance system did not give an overall view of the escalators. The capabilities and overview of the system did not allow developing problems to be identified at an early stage. The placement of the monitoring system cameras precluded the vessel's engineers from continuously monitoring the whole length of any of the six escalators in use at the time of the occurrence.Causes and Contributing Factors The placement, size and content of passenger instruction signs in the escalator towers were inadequate to ensure that passengers on foot proceeded to the correct deck to disembark. Some unsupervised students mistakenly left the tower at the upper car deck level. When the students attempted to rejoin the flow of passengers in the tower, they were hindered by a control barrier at the foot of the escalator and by the bulky baggage they and the passengers on the escalator carried. The area quickly became congested and passengers on the moving escalator were unable to leave it. Two of the many passengers who fell backwards were injured, one of whom required hospitalization. The escalator surveillance system did not give an overall view of the escalators. The capabilities and overview of the system did not allow developing problems to be identified at an early stage. The placement of the monitoring system cameras precluded the vessel's engineers from continuously monitoring the whole length of any of the six escalators in use at the time of the occurrence. Following this occurrence, Transport Canada and the BCFC reviewed the three ferries fitted with escalators (QUEEN OF COWICHAN, QUEEN OF COQUITLAM and QUEEN OF ALBERNI). Modifications were made to the QUEENOFCOWICHAN; the closed circuit TV screens were transferred to the chief steward's office for monitoring by a catering attendant as a sole duty while the escalators are in use, and an elevator has been installed to reduce the load on the escalators. It has also been transferred to a non-commuter route with fewer foot passengers and school parties travelling, and therefore lessening the congestion on the escalators. BCFC has also informed group users of the availability of baggage carrying facilities. (The vessel which replaced the QUEENOFCOWICHAN is fitted with stairs and three elevators.) The QUEEN OF COQUITLAM and QUEEN OF ALBERNI are now used only where foot passengers do not have to use stairwells / escalators for embarking / disembarking. This reduces the risk of foot passengers getting lost in the stairwells. Since the accident, the announcements of impending arrival at terminals have been advanced on all ferries, allowing passengers more time to make their way to their car or to the disembarkation point.Safety Action Taken Following this occurrence, Transport Canada and the BCFC reviewed the three ferries fitted with escalators (QUEEN OF COWICHAN, QUEEN OF COQUITLAM and QUEEN OF ALBERNI). Modifications were made to the QUEENOFCOWICHAN; the closed circuit TV screens were transferred to the chief steward's office for monitoring by a catering attendant as a sole duty while the escalators are in use, and an elevator has been installed to reduce the load on the escalators. It has also been transferred to a non-commuter route with fewer foot passengers and school parties travelling, and therefore lessening the congestion on the escalators. BCFC has also informed group users of the availability of baggage carrying facilities. (The vessel which replaced the QUEENOFCOWICHAN is fitted with stairs and three elevators.) The QUEEN OF COQUITLAM and QUEEN OF ALBERNI are now used only where foot passengers do not have to use stairwells / escalators for embarking / disembarking. This reduces the risk of foot passengers getting lost in the stairwells. Since the accident, the announcements of impending arrival at terminals have been advanced on all ferries, allowing passengers more time to make their way to their car or to the disembarkation point.